1265794317 NPI number — LA MICHOACANA DENTAL CLINIC #2

Table of content: (NPI 1265794317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265794317 NPI number — LA MICHOACANA DENTAL CLINIC #2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA MICHOACANA DENTAL CLINIC #2
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265794317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6500 SPENCER HWY
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77505-1704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-416-4385
Provider Business Mailing Address Fax Number:
281-741-9546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 SPENCER HWY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77505-1704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-416-4385
Provider Business Practice Location Address Fax Number:
281-741-9546
Provider Enumeration Date:
06/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MONTY
Authorized Official First Name:
ADELINA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-416-4385

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  18185 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QD0000X , with the licence number: 27247 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 126781986 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 270255489 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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